Another battle over ACA repeal looms

When Congress returns from break, repealing and replacing the Affordable Care Act will again be at the top of Republicans' to-do list. But it remains unclear if the House is any more likely to pass a bill this time around.

President Donald Trump believes that he can't pass big, permanent tax cuts until the ACA's spending and taxes are cut way back. "Healthcare is going to happen at some point," Trump said last week. "But the tax reform and the tax cuts are better if I can do healthcare first."

The ACA repeal-and-replace bill would erase nearly $1 trillion in taxes and $1 trillion in spending, which would help Republicans enact permanent tax cuts through budget reconciliation legislation. Such legislation can be passed on a straight party-line vote. To use reconciliation, though, the tax bill could not increase the budget deficit after 10 years, under Senate rules.

But healthcare legislation remains an uphill battle. The ultraconservative House Freedom Caucus wants to gut the ACA's insurance regulations requiring minimum essential benefits and modified community rating, allowing insurers to charge older people and those with pre-existing conditions higher rates.

More moderate House and Senate Republicans are leery about those changes, as well as the projection that the bill would spike premiums in 2018 and 2019 and lead to 24 million fewer insured people. Democrats strongly oppose the legislation.

Republicans would have to move fast. They have to pass a bill to fund the government by the end of this month. If they can't agree on a healthcare bill to fold into the budget reconciliation, they won't get another shot at reconciliation until late summer or fall, when they also want to enact tax reform.

In addition, Trump and Congress need to provide certainty for insurers, who have until June to decide whether to offer individual-market plans and how much to charge.